Monthly Archives: December 2008

I wanted to post this reply to a commenter who wanted to tell me not to link midwifery and abortion in the spectrum of reproductive choice and good reproductive medicine on my own blog.

With all due respect, many people do think the two are intimately linked as the full spectrum of legal reproductive rights. I am happy the journal and the American College of Nurse Midwives took this position. They are supporting medical care above ideology.

There is a difference between being pro-life personally and being for making all forms of induced abortion illegal, which increases maternal death (and cannot be pro-life) and does not reduce abortion rates. If it can be legally and safely performed for any of a variety of reasons, which it thankfully can be in our country, I am for midwives being trained to perform them and licensed to perform them, if that is what they consider to be in their scope of practice. First trimester abortions, which constitute 95% of abortions, are simple, safe procedures that can easily be done by a midwife.

All health care providers get to decide what we consider to be ethical practice. Some may refuse to deliver homosexual or transgender patients, some may refuse to perform abortions, some may refuse to attend illegal aliens. Some may refuse to provide birth control.

I will personally refuse to do circumcisions. If any patients ask my opinion on it, I will tell them. Female circumcision is illegal in this country, so I will not refer out for it. Male circumcision is still legal, so I will refer out any patients who wish to circumcise their male infant.

Deciding to limit one’s own practice does not give anyone the right to unilaterally remove an issue one personally finds offensive from everyone’s discussion.

“Advocates of health reform who focus exclusively on access presume that the United States provides effective but expensive healthcare, and that the only real problem is lack of access to this care. The reality is more complex when we examine those mortality figures… [T]he United States ranks last in infant mortality, third to last in perinatal mortality (deaths in the first seven days and fetal deaths), and last in maternal mortality… While the US infant mortality rate improved marginally – 3 percent – since 2000, the 15 comparison countries, which already had much better rates, improved by 21 percent in the same period. Put in concrete terms – if the US infant mortality rate merely equaled the current average rate of the other 15 industrialized countries, there would be more than 11,000 fewer infant deaths every year in the United States.

The biggest recent shift in maternity care has been a 50 percent rise in the cesarean rate since 1996 to 31.1 percent (third highest among the 16 countries) in 2006. This is testimony to the US belief that more medical intervention, regardless of cost, is better – even when the evidence doesn’t support such a claim. A blind acceptance of medical interventions is a systems problem that won’t be solved by expanding health insurance coverage.

The first step in improving outcomes is recognizing that our problems go beyond access to care. Our poor showing can’t be shrugged off as a function of some subgroup – the uninsured, minorities, immigrants (some generic “them”) having health problems that undermine otherwise solid outcomes. This is not just about who gets care, but about how they’re cared for. Expanding access to a system that doesn’t work won’t change these embarrassing rankings.”

Not only is childbirth the most common reason for a hospital stay — more than 4 million American women give birth each year — it costs the country far more than any other health condition. Six of the 15 most frequent hospital procedures billed to private insurers and Medicaid are maternity-related. The nation’s maternity bill totaled $86 billion in 2006, nearly half of which was picked up by taxpayers.

We spend more than double per capita on childbirth than other industrialized countries, yet our rates of pre-term birth, newborn death and maternal death rank us dismally in comparison… The U.S. ranks 41st among industrialized nations in maternal mortality. And there are unconscionable racial disparities: African American mothers are three times more likely to die in childbirth than white mothers.

The problem is not access to care; it is the care itself. As a new joint report by the Milbank Memorial Fund, the Reforming States Group and Childbirth Connection makes clear, American maternity wards are not following evidence-based best practices… The most cost-effective, health-promoting maternity care for normal, healthy women is midwife led and out of hospital. Hospitals charge from $7,000 to $16,000, depending on the type and complexity of the birth. The average birth-center fee is only $1,600 because high-tech medical intervention is rarely applied and stays are shorter. This model of care is not just cheaper; decades of medical research show that it’s better… The Obama administration could save the country billions by overhauling the American way of birth.

Consider Washington, where a state review of licensed midwives (just 100 in practice) found that they saved the state an estimated $2.7 million over two years. One reason for the savings is that midwives prevent costly caesarean surgeries: 11.9% of midwifery patients in Washington ended up with C-sections, compared with 24% of low-risk women in traditional obstetric care.

Currently, just 1% of women nationwide get midwife-led care outside a hospital setting. Imagine the savings if that number jumped to 10% or even 30%.

Introductory discussion: This discussion group will be primarily focusing on maternal and pediatric health. Not only is that the vocations, areas of expertise and interest of our participants, but it is a critical area of importance and area in which a great impact can be made in outcomes and in costs.

Informed choice, informed consent is key. Patients cannot make true informed choices without adequate, non biased information and access to all of their options in care. This includes alternative birthing options, such as freestanding birth centers, and the ability to refuse or delay treatment, such as vaccines in children with autoimmune disorders.

Practitioners at the meeting have seen midwifery care integrated into hospital systems seamlessly in other countries with better infant and maternal mortality and morbidity rates than the United States: Ireland is an example. One pediatrician at the meeting trained for a year in Ireland and saw the majority of low risk births delivered by midwives with excellent outcomes. (Ireland ranked lowest in the world in maternal mortality rates, 1 in 100,000 live births, while the United States had 11 in 100,000, WHO Maternal Mortality in 2005, http://www.who.int/whosis/mme_2005.pdf, Accessed Dec. 30, 2008)

Simply improving access isn’t enough. Leading a horse to water isn’t enough if it’s bad water. Practitioners are not practicing evidence based medicine. Standard of care is not based on evidence based medicine. Malpractice suit outcomes and testimony are not based on evidence medicine. This is leading to expensive interventions, worse outcomes for mothers and their children, and tension between different types of practitioners.

There are also problems in the current system – practitioners are not getting paid. Midwife centers are not getting paid, ERs are not getting paid, and major hospitals are closing their doors. With all of the money we are spending, people are not getting good care, and practitioners are not getting reimbursed. The birth center sponsoring the meeting estimates that they are not reimbursed for 25% of their health services delivered, and Florida law is more progressive than some states in supporting coverage of midwives by insurance, including Medicaid.

Questions:
1. Briefly, from your own experience, what do you perceive is the biggest problem in the health system?
• Not every state has legalized midwifery or legalized homebirth. We need consistent access and consistent licensing. This should apply to nurse midwives and lay (certified professional midwives) midwives. Midwives should have access to medicines and licensing and insurance to cover treatment of minor complications of low-risk, normal births within the scope of their training.
• Women are not informed about their health choices, such as choosing an alternate practitioner or location for birth. For example, at one Ob/gyn practice, a member of the group observed a pamphlet entitled “Birthing options” included only cesarean section or vaginal birth, with or without an epidural, at a hospital.
• There is a serious problem with the definition of standard of care. If practitioners in the local geographical area do not support midwives, do not support low intervention birth, do not support evidence based practices such as birth in freestanding birth centers, allowing trial of labor for attempted vaginal deliver after cesarean delivery (VBAC), intermittent fetal monitoring, food and drinking during labor, continuous labor support, avoidance of episiotomy, freedom of movement in labor and delivery, etc, then these practices can be vulnerable to malpractice cases and ostracization in the local medical community, including a lack of reimbursement and hospital privileges. This hostile environment discourages practices that save money, provide patient choice and satisfaction, and save lives of mothers and children. The cesarean rate in South Florida is rapidly approaching an astonishing 50%, and that should not be an appropriate standard of care for ob/gyns to defend in malpractice cases.
• In pediatrics, locally there is a lack of continuity of care. Pediatricians are not following contemporary recommendations by professional health organizations. This is especially a problem with nutrition and breastfeeding.
• There is a problem with overtreatment and overmedicalization in pediatrics, also. The pediatrician and the midwives have noticed a tendency for many practitioners to lumbar puncture every child that presents with a minor fever. Doctors are prescribing medicines, such as albuterol, that they know don’t work. Doctors need to keep up with continuing education and evidence based recommendations for practice.
• Is there anything that holds pediatricians to evidence based standard of care? If the American Academy of Pediatrics recommends one practice as a standard of care, but the doctors in the community are making other recommendations contrary to the recommendations, what recourse do consumers have? Even the most educated consumers have problems discerning good medical information on the internet, and many practitioners are not open to patients who advocate for their own care, especially if their information is contrary to the advice of the practitioner. One midwife in the meeting described being “fired” by her children’s pediatricians for bringing in information supporting extended breastfeeding. In regards to informed consent, the only recourse right now for consumers to inform themselves.
• One member of the group suggested public service messages that advertise phone numbers and websites that give out individualized health advice and that complete, unbiased health options (access to other practitioners, like midwives should be available from these sites.)
• Start educating children in health classes in school, or sex ed, making people aware of their options for out of hospital birth.
• Career days are a good option for alternative practitioners like midwives at all levels of education, starting in elementary school.
• Insurance companies should talk about midwives and out of hospital birth as options.
• Maternity care should always be covered by all insurance plans. One member of the group had an experience in which she was insured, but wanted to add maternity coverage. The insurance company refused to allow her to add maternity coverage unless she took a series of negative pregnancy tests. Pregnancy should never be a preexisting condition, especially if a woman has received no prenatal care yet. Early and consistent prenatal care is so important; no one should have to forego prenatal care based on insurance bureaucracy.

2. How do you choose a doctor or hospital? What are your sources of information? How should public policy promote quality health care providers?

• People usually get references from educated consumers or references from friends in the field.
• Most people in the room go to who is covered by insurance, but there is little information from the companies about the nature of the practice.
• Interviewing the practitioner is important.
• Check how the office staff responds to you.
• People would have improved options with universal single payer coverage.
• Doctors who make home visits would be nice.
• See answers to question #1 regarding public health information websites and phone lines, and standards of care based on evidence based medicine, not local practitioners.

3. Have you or your family members ever experienced difficulty paying medical bills? What do you think policy makers can do to address this problem?

• Yes, many people have had problems paying bills.
• Single payer universal program would solve this problem.
• No one should go bankrupt to pay hospital bills. No one should choose between medicine and food. No one should choose between her current children’s day care and prenatal visits.
• Insurance companies and employers have saving accounts to pay health bills. We could pay taxes to make these savings accounts.
• Health care costs could be decreased by preventative programs (fitness, nutrition).

4. In addition to employer-based coverage, would you like the option to purchase a private plan through an insurance-exchange or a public plan like Medicare?

• Some people don’t have employers to cover them. This system fails small business owners and the self employed.
• Public system preferred by all. People can buy supplemental insurance or pay for elective procedures if they wish.
• Single payer universal plan preferred by all.

5. Do you know how much you or your employer pays for health insurance? What should an employer’s role be in a reformed health care system?

• Employers and individuals pay way too much for inadequate health plans.
• Employers can pay taxes and stop having to pay for the insurance and stop having to pay salaries to human resource personnel who handle negotiating complicated insurance plans.
• They can play a role in preventative care and dispersing information. They can provide time for exercise, provide healthy food, sponsor groups like Weight Watchers.
• Small businesses struggle with being able to provide special perks and extra flexibility. It would be better if they had more support, tax breaks, and financial incentives.

6. Have you gotten the prevention you should have?

• Birth control is essential to preventative medicine. Women spend 5 years trying to get pregnant, and about 25 trying not to. 98% of women in the United States use birth control at some point in their lives, and about 50% of pregnancies are unplanned. About half of these unplanned births end in abortion.
• All insurance should provide birth control. All pharmacies should provide birth control and emergency contraception. All hospitals should offer emergency contraception.
• As for preventative care of all kinds, don’t just note how many people didn’t receive it, note how many weren’t offered the preventative care. But, allow people to decline. People need informed consent.
• Some people don’t notice people not knowing about flu shots and mammography. We live in a dense, urban area, however.
• Universal dental care, especially for children.
• Universal mammography and new technologies such as MRI for breast cancer screening should be supported.
• Optometry and hearing care for children should be provided through schools, including hearing aids and glasses. If children get screened, there should be follow through and access to care and devices.
• Parents need to know how to work the system. People should not have to work so hard to access care.
• Longer maternity leave!!!!
• More sick days.
• Women sit in clinics for 7 hours to get a 15 minute prenatal visit at a public clinic. They avoid prenatal care and have higher complication rates. This is why women show up in labor without adequate prenatal care.
• High schools should have good information and access to adequate sex education, access to birth control, access to prenatal care and access to daycare and health services for children of teenage mothers.

7. How could public policy promote healthier lifestyles?

• We need to retrain health care professionals. They are too centered on drugs and overmedicalization.
• Mandating PE and recess programs need to be enforced in schools. More indoor facilities for PE.
• Treat healthy patients like healthy patients. Don’t overmedicalize patients in labor.
• Accountability! For practitioners to practice evidence based medicine.
• Good food and nutrition in schools.
• Public schools with gardens. Public gardens in cities.
• Access to healthy food in all neighborhoods and areas.
• Less environmental pollution and pesticide use, more local growing of foods.
More funding of alternative medicine, more promotion of these alternative methods. Expand federal funding of alternative and complementary medicine, and cooperate with other countries to learn from their successful integra

I tried to get a little ranty at the commenters (with display names like “Obstetrician”) who tried to say that higher risk births are the reason why we have such dismal rates of maternal and perinatal mortality. And, a few moms came on and said that her article was somehow making them feel like less of mothers because they chose epidurals. (Not that it said that anywhere in the article, or even hinted at it. They win a square on Mommy Wars Bingo!) But, there was a comment length limit I seriously exceeded.

Here is my attempted reply:

I have a hard time hearing obstetricians complain about the dangers of out of hospital birth when in hospital births are full of so much iatrogenic morbidity! Forget how bad unproven continuous external monitoring is, how many hospitals have pushed internal fetal monitoring, often on all of patients, regardless of risk? We had the closest major teaching hospital lose THREE infants to herpes encephalopathy recently before they stopped that barbaric and unproven practice.

Also, no one said that mothers who opt for pain medicine or an elective cesarean are less of a mother. I am so tired of having all of these discussions turned away from talking about better outcomes for ALL mothers to a few complaining about feeling guilty and inadequate about their birth choices. Birth choices are health decisions. Make yours with informed consent. Let others make theirs with informed consent.

Pain medication and elective cesareans have worse outcomes for mothers and neonates. That is a risk many women are willing to accept, that is their choice, but it does not need to stamp out every conversation about the risks of interventions in birth. Other people need to be able to make choices based on complete information, too.

Share this:

Like this:

The Journal of Midwifery & Women’s Health sent me a table of contents alert to my email inbox. Wheee!

I was so thrilled to see a progressive editorial (paywall) about supporting abortion choices and performing abortions. I was especially pleased to see the recommendation that “women with limited means should have access to financial resources for their reproductive choices” and that “every woman has the right to access factual, unbiased information about reproductive choices, in order to make an informed decision”.

Share this:

Like this:

I have been enjoying my time off. I have spent time with family and friends. I have cooked and eaten. I have played and napped.

Sleeping has been hard. There have been some good full nights of sleep, don’t get me wrong. But, at least twice already I have felt like there is some crisis I am supposed to be handling, some urgent responsibility on my shoulders as I tossed and turned all night. I guess I am so used to a certain level of stress that my body is creating its own. I am kind of relieved by that. Sometimes I look ahead toward rotations and residency and wonder if I am cut out for it. I think I thrive on tension, and that is a curiously good sign.

I have also been plagued by intense waves of déjà vu. I will be standing at the kitchen sink, staring out at the yard and the canal, daydreaming, and this overwhelming nostalgia from some unknown time takes over. I think I have finally figured it out. I am flashing back to when I had daydreaming time. Times earlier in my life where I didn’t really have any responsibilities. On these short vacations, I actually get to a point where I almost feel carefree at times. I guess it is so rare these days, it takes me back to when it wasn’t.